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Norton Healthcare Network Resource Request Form NEW ACCOUNT CHANGES TO ACCOUNT DELETE ACCOUNT This form should be used to request all network computer resources except for RemoteLINK Remote Access Meditech CareLINK Kronos and Cyberview. Access forms for these applications can be obtained from the Nsider Forms Library or the Support Center 629-8911 option 1. Please TYPE or PRINT all information clearly and in FULL* Illegible information or unauthorized signatures will result in slower process time or rejection of the request. One employee per form please. LAST NAMEFIRST NAME MI EMPLOYEE I. D. or Social Security Number if Vendor or Non-Norton Employee FACILITY NAME DEPARTMENT NAME DEPT. PHONE NUMBER NAME OF COMPANY IF VENDOR / CONSULTANT HOW MANY MONTHS WILL THE VENDOR/CONSULTANT USE THIS ACCOUNT CHECK ALL THAT APPLY EMPLOYEE REQUIRES E-MAIL ACCESS YES NO LIST GROUPS APPLICATIONS SHARED DRIVES ETC. REQUESTED Option Submit the name and network ID AHSNXXXX VENDXXXX of another employee in the work area who already has exactly the same access as that which is being requested Desktop applications such as word processors spread sheets graphics and electronic mail have only one level of access. AUTHORIZING SIGNATURE Date Norton Management level signature required Please Print Name Title Return Mailing Address please specify e-mail or interoffice Please note If an employee changes in any given position please submit requests to reconcile the change in ownership* It is not acceptable for a new employee to inherit the account of a predecessor. Each account must be unique. Documents spreadsheets etc* can be copied to the home directory of the new employee. Account information will be e-mailed to the manager unless specified otherwise above. Fax Number to send requests 629-5149 IS Security Administration* For questions or assistance please call the Norton Service Center 629-8911 option 1 Revised 12/2009 mb. Access forms for these applications can be obtained from the Nsider Forms Library or the Support Center 629-8911 option 1. Please TYPE or PRINT all information clearly and in FULL* Illegible information or unauthorized signatures will result in slower process time or rejection of the request. Please TYPE or PRINT all information clearly and in FULL* Illegible information or unauthorized signatures will result in slower process time or rejection of the request. One employee per form please. LAST NAMEFIRST NAME MI EMPLOYEE I. D. or Social Security Number if Vendor or Non-Norton Employee FACILITY NAME DEPARTMENT NAME DEPT. One employee per form please. LAST NAMEFIRST NAME MI EMPLOYEE I. D. or Social Security Number if Vendor or Non-Norton Employee FACILITY NAME DEPARTMENT NAME DEPT. PHONE NUMBER NAME OF COMPANY IF VENDOR / CONSULTANT HOW MANY MONTHS WILL THE VENDOR/CONSULTANT USE THIS ACCOUNT CHECK ALL THAT APPLY EMPLOYEE REQUIRES E-MAIL ACCESS YES NO LIST GROUPS APPLICATIONS SHARED DRIVES ETC. PHONE NUMBER NAME OF COMPANY IF VENDOR / CONSULTANT HOW MANY MONTHS WILL THE VENDOR/CONSULTANT USE THIS ACCOUNT CHECK ALL THAT APPLY EMPLOYEE REQUIRES E-MAIL ACCESS YES NO LIST GROUPS APPLICATIONS SHARED DRIVES ETC. REQUESTED Option Submit the name and network ID AHSNXXXX VENDXXXX of another employee in the work area who already has exactly the same access as that which is being requested Desktop applications such as word processors spread sheets graphics and electronic mail have only one level of access.

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